arteries

bp cuff should be ____% of arm circumference

40%

a 30% of arm circumference bp cuff width will…

overestimate bp

*narrow cuff=overestimate bp

*wide cuff=underestimate bp

when to NOT use arm for bp

side of post-mastectomy or dialysis fistula

minimum inflation pressure to assure complete cessation of flow

20-30mmHg

LE pulse point that is most difficult to palpate

pop A

4 main pulse points:

CFA/SFA

pop A

PTA

DPA

calf vessels best seen w posterolateral approach

peroneal

where is retrograde flow normal in relation to distal anastomosis (@vessel end)?

just prox to it

A: brachial artery

B: common interosseous artery (branch of ulnar @prontaor teres)
C: radial artery
D: ulnar artery

artery mc used for arterial line placement

radial

artery renamed at lower teres major muscle

brachial

*from axillary artery at lower teres major

artery that gives rise to deep palmar arch is ___

artery that gives rise to superficial palmar arch is ___

radial (deep)

ulnar (sup)

A: PTA
B: Peroneal artery
C: ATA

only vascular structure post to IVC

RRA

layers

tunica intima:

• inner, endothelial cells

• permeability, antithrombogenic, vasoreactivity

tunica media:

• middle, thicker, smooth muscle, circular

• regulate size

tunica externa:

• outer, fibrous connective tissue, longitudinal

• contains vasa vasorum

EVAR
TCAR
endartectomy

EVAR: stent in AAA
TCAR: stent in carotid
endartectomy: clear out plaque

mc site of pseudoaneurysm

CFA

endoleak types after AAA EVAR

*flow outside EVAR graft

type I: incomplete seal at ends

type II: sac fill via branch vessel (retrograde)

type III: stent defect/tear

type IV: porous graft

type V: AAA expansion w/out leak site

SMA feeds

intestines (lower duodenum)

transverse colon

pancreas

phasic flow…

pulsatile flow…

phasic: fluid movement that changes over time w breathing

pulsatile: fluid movement that changes over time from heart beating

IIA feed…

pelvic wall, gluteal, thigh, peritoneum

amount of blood ejected per beat

SV

high contractility=high SV

*CO=SVxHR

BP is controlled by…

CO & peripheral resistance

large vs small SV

large SV: spectral broadening

• parabolic flow

• diastole

small SV: open spectral window

• plug flow

• systole

do dilated arterioles have lots or little diastolic flow?

lots

*in exercise bc high demand distally (high flow volume)

normally…what happens to ankle P post exercise?

stays same or slight increase

**take P every 2min post exercise if drops

moderate steonsis

severe stenosis

PAD RF

genetic

HLD, HTN, DM

PAD

manifestation of atherosclerotic process

• reduced flow bc narrowed arteries

claudication

pain of LE during exercise & relieved w rest

bc inadequate flow

S&S:

• cyanosis/pallor/rubor, cold, pain

raynauds

small vessel vasospasm

primary: bc arterial spasm; intermittent ischemia of fingers & toes

• normal at ‘rest’ (w no irritant)

secondary: bc arterial obstruction; constant ischemia & rest pain

• bc underlying disease

dependent rubor

limb elevation causes pallor & limb lowering returns to normal color

P’s of acute arterial disease

pain, pallor, pulselessness, paresthesia (numb), paralysis, poikilothermia (cold)

palpable pulse points

AO

fem, pop

DP, PTA

**0=no pulse; 4=bounding

atherosclerosis

thick intima (wall)

RF:

• HLD, HTN, DM

• genetics, male, smoking

mc @bif, intrarenal origin, brachiocephalic origin, pop trifurcation

buergers disease

“thromboangiitis obliterans”

small vessel thrombosis; ‘fixed’ occlusive disease

spares vessel walls

mc arteritis

men, <40yo, smoker

rest pain, ulcerations

types of aneurysms

true: at least 50% dilation of all wall layers

dissecting: small tear in intima; flow in new lumen

psuedo: hole in wall allows blood to escape & form hematoma pocket; always communication ‘neck’ of flow present

mc aneurysm locations

thoracic AO (infrarenal)

fem, pop

carotid

renal, splenic

entrapment syndrome

mc in pop

bc pop a compression by gastrocnemius muscle

young men

calf pain in exercise

interosseous artery runs…

off ulnar artery and runs btwn radius & ulna

UE atherosclerotic occlusive disease in which vessels?

subclavian & innominate arteries

thoracic outlet syndrome TOS

intermittent pain/numbness based on arm position

may lead to thrombosis or subclavian aneurysm

female

pain/paresthesia in hand

cold immersion test

*episodic vasospasm

submerge hand for 1-2min

waveform will decrease & should return to baseline w/in 5min

reduced amplitude >8-10min = vasospasm

hand warming test

*vasospasm vs small vessel disease

warm hand for 5min

no waveform improvement = fixed occlusive disease

allen test

*palmar arch patency

should be no drop in PPG amplitudes

compress RA & UA to determine patency or dominance

abnormal subclavian artery distal to stenosis

delayed rise time

arterial symptoms vs venous symptoms

analog vs FFT

analog: zero-crossing frequency

FFT: spectrum analyzer

• displays ALL freq & amp

• more sensitive bc more freq

AT

normal: <133m/sec

prolonged AT if obstruction prox to probe

no prolonged AT w obstruction distal to probe

pulsatility index PI

quantify waveform in high resistance beds

normal:

• CFA > 5.5

• Pop = 8

bladder width should be…

20% wider than limb diameter

40% wider than limb circumference

segmental P (can NOT/can)…

can NOT determine exact location of disease

can NOT differentiate stenosis v occlusion

can be falsely elevated w calcified arteries (DM)

compare 3 cuff & 4 cuff methods to brachial P

3 cuff: thigh P = brachial P

4 cuff: prox thigh P 30mmHg > brachial P

do not exceed _____mmHg w segmental P

220mmHg

diabetics ankle P & toe P

ankle: very different P than non-diabetics

toe: lil P difference than non-diabetes

for ABI do you use the higher or lower brachial P?

higher

resting ABI values

(>1.35) probable calcified

(0.9-1.34) normal

(<0.9) stress test

(<0.8) probable claudication

(<0.5) multi-level disease

(<0.3) ischemic rest pain/pallor/severe disease

TBI values

normal: >0.75

abnormal: <0.66

*toe P more reliable than ankle P

*normal for toe P to vary 60-80% of ankle P

P drop btwn segments (PPG) that is significant

drop 30mmHg

where is the problem?

LT inflow disease & fem-pop disease

ankle P for single v multilevel disease

single: ankle P recover 2-6min post exercise

multi: ankle P recover 12min post exercise

*do NOT exercise w rest pain or ulcers

reactive hyperemia

body’s own way of increasing flow after ischemia

procedure type alt for exercise:

• inflate thigh cuff 30 above brachial P for 5min…ischemia…vasodilation

pulse volume plethysmography PVR

measure changes in extremity volume

combo w doppler waveforms & segmental P to determine vascular origin or other

can NOT:

• tell btwn major artery & collateral

• be specific to single vessel

is UE stenosis common or uncommon?

uncommon

prox to UE occlusion w PW…

‘thump’ can be heard

significant stenosis in LE occurs at…

level of adductor canal in distal SFA & prox Pop A

%stenosis ration w PSV

prestenotic PSV:stenotic PSV

• increase >100% (2:1) is 50% d reduction

• (4:1) is 75% d reduction

normal finger/brachial value

0.8-0.9

where is fem artery pulse best felt?

femoral triangle

ABIs (PPG v PVR v segmental P)

look at presence & severity of disease, NO location

PPG: toes (esp w calcified)

PVR: obtains waveforms w P (inflate 65mmHg)

segmental P: looks at level of disease (old way)

mc location of LE arterial lesions

distal SFA

ATA

feeds anterior leg & dorsal surface

passes ant to popliteus muscle…btwn tib/fib...interosseous muscle

runs anterolateral leg

PTA

feeds foot sole

down medial posterior leg; posterior to medial ankle

divides into med/lat plantar a

PERO A

feeds lat lower leg & calcaneus

down lateral posterior leg, along fib

into ant/post perforators

plantar arch

feeds digits, skin, foot muscle

deep plantar a (from DPA) + lat plantar a (from PTA)

arteries around knee

• genicular branches

• muscle branches

• sural arteries

axillary artery originates at…

lateral margin of 1st rib (from subclavian a)

radial a into…

ulnar a into…

(radial)…deep palmer arch

(ulnar)…superficial palmar arch

flow type in AO

plug

**other arteries have laminar flow

most arterial disease is due to…

atherosclerosis

common locations of cardio-emboli

AO bif

iliacs

fem bif

Pop a

mc location for pseudoaneurysm

groin

pseudoaneurysm US

*US w doppler is best method

to-and-fro flow

high V bruit

‘yin-yang’ color sign

takayasu’s arteritis

affects large vessels, AO & branches

• brachiocephalic, CCA, sbclvn a

young, asian women

HTN, low peripheral pulses, AR

most patients w calf claudication have…

stenosis or occlusion of SFA

leriche’s syndrome

bilateral thigh/butt claudication w ED

• impotence bc low flow thru hypogastric a (IIA)

w/ AO-iliac disease

where is ischemic rest pain most often felt?

metatarsal heads of feet

*pain lessens w dependency (hanging)

• difference from diabetic neuropathy

*needs immediate attention

loss of palpable pulse indicates…

prox occlusion

*pulse grading

• 0: no palpable pulse

• 4: excessive pulse

arterioles have _____ flow

steady (rather than pulsatile in arteries)

are P drops in arterial disease more apparent at rest or exercise?

exercise (bc increased flow)

**severe disease can be diagnosed @rest

normal arterial tracing PVR

rapid upstroke

sharp peak

dicrotic notch

mildly abnormal arterial tracing PVR

rapid upstroke

sharp peak

absent dicrotic notch

bowed downslope

moderately abnormal arterial tracing PVR

flat peak

upslope=downslope

absent dicrotic notch

severely abnormal arterial tracing PVR

low amplitude

no pulsatility

waveforms at rest vs in exercise

(at rest) high resistance, triphasic

(in exercise) low resistance

arterial claudication

(postural changes) not cause pain

(walking) symptoms

(standing) relieves

(sitting) relieves

(stationary bike) symptoms

(pulses) abnormal

neurogenic claudication

(postural changes) more pain

(walking) symptoms

(standing) symptoms

(sitting) relieves

(stationary bike) relieves symptoms

(pulses) normal

flow distal to stenosis is…

low resistance & monophasic

popliteal entrapment syndrome

popliteal a compressed by gastrocnemius

• bc repetitive trauma, pop a stenosis/thrombosis

<30yo male

PAD mc symptom

intermittent claudication

leriche syndrome

“AO iliac occlusive disease”

bc severe atherosclerosis of distal AO, iliac a, fem-pop

• claudication

• impotence

• absent fem pulse